hematology/anemia

Hematopoeisis

formation of blood cells

remainder of blood NOT formed into elements is called

plasma

two stages of the hematopoietic system

1. proliferation (miotic division)
2. differentiation (maturation)

Stem Cell System

allows for rapid response to altered cell #s OR invasion of foreign organism

3 primary blood cells

1. Leukocytes (WBCs)
2. Thrombocytes (platelets)
3. Erythrocytes (RBCs)

5 types of leukocytes (WBCs)

Neutrophils

Lymphocytes

Monocytes/Macrophages

Eosinophils

Basophils

Function of leukocytes

body’s defense system & removes debris

what does a **left shift** mean?

more neutrophils

neutrophils are composed of…

segs and bands

what is the difference between segs and bands

segs = mature neutrophils

bands = immature neutrophils

a high % of bands indicate…

bacterial infection

Where do lymphocytes mature?

thymus

Lymphocytes are also known as…

T & B cells

Leukocyte that is primarily an immune response

lymphocytes

Monocytes

immature macrophages

(monocyte/macrophage) - which appears on WBC differential?

monocytes

T/F: monocytes & macrophage is stored in the bone marrow

F - NO reserve in bone marrow

T/F: monocytes/macrophages have a __slow__ peripheral turnover

T

Which leukocyte initiates & mediates immune response and can digest dead/defective host cells?

monocyte/macrophage

an increase # of eosinophils can indicate…

allergic reactions

parasitic infections

cancer

Type of leukocyte directed towards large invaders (parasites) OR part of an allergic reaction

Eosinophils

pro-inflammatory response

eosinophils

leukocyte responsible for inflammatory reaction

basophils

Basophils release multiple substances such as…

heparin

bradykinin

histamine

Stress can cause neutrophils to become _________

demarginated

an increase of demarginated neutrophils can cause

increase % of total WBCs

Function of platelets

essential for bleeding control & coagulation

Thrombopoiesis

platelet production

Platelets are composed of…

cytoplasmic fragments (portions of another cell)

where is 1/3 of platelets stored?

in the spleen

T/F: thrombocytes have a long life span

F - 10 days

function of erythrocytes

tissue oxygenation

T/F: erythrocytes can reverse deformity

T - allows movement through small capillaries

Where does RBC destruction occurs

spleen

Hemoglobin makes up ____% of erythrocytes

90%

Hemoglobin

oxygen-carrying component of cell

largest iron compartment in the body

Erythropoietin

released by kidney & accelerates the maturation of existing erythroblasts

T/F: administration of EPO does NOT produce immediate increase in RBCs

T

Reticulocyte

immature erythrocyte

Erythropoiesis

RBC production

T/F: most iron & amino acids from globin returns for reuse

T

Bilirubin

waste produced from RBC destruction process

Where is bilirubin conjugated for excretion?

liver

hemoglobin molecule is composed of

4 globin molecules + 4 heme molecules

Transferrin

plasma transport protein

T/F: Transferrin is a negative feedback mechanism

F

Describe Transferrin’s positive feedback mechanism

binds to serum iron receptors for transport to store OR more immediate recycling

requirements for hemoglobin synthesis

formation of protoporphyrin

availability of iron/heme

generation of proteinaceous globin

Types of hemoglobin

Oxyhemoglobin

deoxyhemoglobin

methemoglobin

oxyhemoglobin

hemoglobin carrying oxygen

Deoxyhemoglobin

aka reduced hemoglobin

released oxygen & isn’t currently bound to oxygen

It is common for people who are often exposed to exhaust to have this type of hemoglobin

methemoglobin

methemoglobin

unstable hemoglobin NOT capable of binding due to addition of oxidized ferric iron

Average adult has how much iron?

4 g

Storage forms of iron

Ferritin

Hemosiderin

Ferritin is stored where

reticuloendothelial cells

Which form of iron is a good indicator of iron stores?

ferritin

Hemosiderin

iron-containing pigment derived from hemoglobin upon disintegration of RBCs (decreased iron availability)

Which form of iron is more stable and has more storage?

hemosiderin

Normal diet provides _____ form (hint: we cannot absorb it)

ferric

Where is ferric ionized to ferrous?

primarily in the duodenum, some in jejunum

T/F: plant heme iron is more easily absorbed

F

What can decrease absorption of iron

polyphenols & calcium

how much iron do we typically lose each day

1 g

T/F: the demand for iron absorption is high in children and pregnant women

T

Circulating iron is taken up by

transferrin (binds to RBCs and other cells first)

RBCs at the end of life are engulfed by

macrophages

iron in macrophages are stored as _____

ferritin

Normal Destruction of Erythrocytes

Decrease metabolism

increase cell fragility

loss of reversible deformability

Phagocytosis by the macrophage breaks globin down into _____

amino acids

porphyrin is reduced to _______

bilirubin

anemia

alteration to RBC/hemoglobin resulting in a decreased capacity to carry & deliver oxygen to tissues

Slow Onset Symptoms

Exertional dyspnea

light-headedness

fatigue

vertigo

skin pallor

headache

weakness

Acute onset symptoms

skin pallor

postural hypotension

tachycardia

dyspnea

light-headedness S

severe symptoms

tachycardia

angina pectoris

high output CHF

systolic murmurs

spoon-shaped nails

Classification of anemias

functional

lab values (depend on age & gender)

morphologic

etiologic

pathophysiologic

iron deficiency

microcytic hypochromic

Diagnostics of iron deficiency anemia

MCV lab value

Symptoms of Iron deficiency

SOB

fatigue

increased workload on heart

tachycardia

dizziness

causes of iron deficiency anemia

blood loss

heavy menstruation

low iron in diet

Laboratory of iron deficiency anemia show **increased**…

total iron binding capacity (TIBC)

Laboratory of iron deficiency anemia show **decreased**…

serum iron

serum ferritin

serum transferrin saturation

Other laboratory findings for iron deficiency anemia

occult blood loss

low % of transferrin saturation

Something you may note in iron deficiency anemia

H/H, RBC is initially normal, but decreases with time

Treatment for Iron Deficiency

dietary supplementation

Ferrous sulfate 325 mg PO TID for 3-6 months

Things to note about Ferrous sulfate

take on empty stomach OR with orange juice if stomach upset occurs

BID or alternate dosing may be available

DO NOT use slow-released products

Side effects of Iron deficiency anemia

nausea (give w/ food)

constipation (most common)

diarrhea (super uncommon, give with food)

epigastric pain

fecal discoloration

Counseling points for iron deficiency anemia

Do not take with milk/calcium

NEED childproof bottle

Do not take with antacids, PPIs, H2 blockers

Can titrate if iron is not well tolerated

Goal of Treatment for iron deficiency anemia

normalize H/H

replenish iron stores

resolve patient symptoms

return normal quality of life/prevent long term complications

Evaluation of therapeutic outcomes for iron deficiency anemia

laboratory (h/h, reticulocyte count, iron study)

Side effects of iron dextran

Anaphylaxis (use a test dose to determine how pt reacts)

Arthralgia

Skin staining

Fever

Lymphadenopathy

Urticaria

Pain @ inj. site (IM only)

Iron Dextran Treatment

IM or (IV – not FDA approved)

Why is IV iron dextran not appropriate

IV needs to be given over multiple, slow infusions (at least 2 hours) & have high incidence of side effects

Monitoring of iron dextran efficacy

laboratory (H/H, serum ferritin, serum iron)

patient symptoms

IV treatment of iron deficiency in patients undergoing chronic hemodialysis who are receiving supplement epoetin-alfa therapy

Sodium ferric gluconate complex

Advantage of sodium ferric gluconate over iron dextran

can be given over faster amount of time

side effects of sodium ferric gluconate complex

cramps

Nausea & vomiting

flushing

hypotension

rash

pruritis

IV iron supplementation used in hemodialysis/peritoneal dialysis patients and chronic kidney disease

iron sucrose

Superparamagnetic iron oxide nanoparticles coated with LMW semisynthetic carbohydrate IV

Ferumoxytol

can be used in children as young as 2 y/o

iron sucrose